Nursing Elites

1. After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?

• A. Infection
• B. Incision
• C. Pain
• D. Tissue perfusion

Correct answer: D

Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.

2. What is appropriate care for a client with neutropenia?

• A. Avoiding fresh fruits and vegetables.
• B. Having a private room.
• C. Wearing a mask when out of the room.
• D. Practicing routine hand washing.

Correct answer: C

Rationale: When a client has neutropenia, they have low white blood cell levels, which increases the risk of infections due to a weakened immune system. Wearing a mask when out of the room is crucial to reduce the risk of exposure to respiratory infections. Avoiding fresh fruits and vegetables is also necessary as they may contain harmful pathogens. Having a private room helps minimize exposure to pathogens and ensures that visitors are carefully screened for any signs of illness. Routine hand washing is essential to prevent the spread of infections in the healthcare setting, but the most direct measure to protect the client from potential infections is wearing a mask when out of the room.

3. Which of the following nursing diagnoses is most appropriate for the client experiencing acute pancreatitis?

• A. Confusion
• B. Latex Allergy
• C. Acute Pain
• D. Constipation

Correct answer: C

Rationale: Acute Pain is the most appropriate nursing diagnosis for a client experiencing acute pancreatitis because it is a common symptom associated with this condition. Pancreatitis often presents with severe abdominal pain that may radiate to the back. Confusion, Latex Allergy, and Constipation are not typically associated with acute pancreatitis. Confusion may occur in severe cases of pancreatitis with complications, but acute pain is the priority nursing diagnosis due to its prevalence and impact on the client's well-being.

4. Which medication should the nurse withhold if the client's blood pressure is 88/50?

• A. Rosuvastatin (Crestor)
• B. Enalapril (Vasotec)
• C. Digoxin (Lanoxin)
• D. Clopidogrel (Plavix)

Correct answer: B

Rationale: Enalapril (Vasotec) is the correct answer. It is an angiotensin-converting enzyme (ACE) inhibitor that can further lower blood pressure. Given that the client's blood pressure is already low at 88/50, administering Enalapril could exacerbate hypotension and compromise perfusion to vital organs. Rosuvastatin (Crestor), Digoxin (Lanoxin), and Clopidogrel (Plavix) are not contraindicated in the context of low blood pressure and may be administered safely.

5. A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?

• A. Verbal teaching in short sessions throughout the day
• B. Provide a pre-operative booklet in Braille
• C. Provide an audio recording for the client
• D. Have the blind patient's family member assist with the instruction

Correct answer: A

Rationale: For a blind patient scheduled for surgery the following morning, the best teaching strategy would be verbal teaching in short sessions throughout the day. Providing information in smaller amounts makes it easier to retain, and one-on-one teaching is most effective. Choice B, providing a pre-operative booklet in Braille, may not be as practical for last-minute teaching. Choice C, providing an audio recording, may not allow for immediate interaction and clarification. Choice D, having a family member instruct the patient, may not ensure the accuracy and clarity of the information provided.

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